Background: Yukmijiwhang-tang is one of the most common herbal formulas in Oriental Medicine. Yukmijiwhang-tang has been widely used as a herbal medicine to replenish Yin and tonify the kidneys for hundred years in Asian countries. Because of insufficiency in data, objective judgements about remedial effects have been difficult. In order to make objectivity diagnostic data, this research is developed. Purpose: The aim of the research is to make a pilot questionnaire for clinical use of Yukmijiwhang-tang. Methods: The questionnaire which includes symptoms and signs for Yukmijiwhang-tang is studied by the Delphi method. Results: By the Delphi method and score evaluation, 30 items of the initial copy of questionnaire are chosen for the research. Conclusions: By the Delphic survey among clinicians, a reference questionnaire for Yukmijiwhang-tang applications was suggested. Further research is necessary for modification of questionnaire by statistics and certification by clinical trial. research.